2 The Oregon Center for Nursing The Oregon Center for Nursing, a 501(c)(3) non-profit organization, was established by nursing leaders in 2002 with a mission to provide the leadership to solve the nursing workforce shortage in Oregon. The Oregon Center for Nursing fulfills this critical leadership role through collaborative work and coordination of a variety of programs, projects, and initiatives in the areas of: Nursing workforce analysis and research Nursing workforce diversity Nursing leadership development Long term care leadership development Support of nursing education initiatives and innovations StudentMAX clinical placement program Oregon Center for Nursing 5000 N. Willamette Blvd., MSC 192 Franz Hall, Room 334C Portland, Oregon tel: fax: Thank you to the following partner agencies for contributing photos used in this report: Columbia Gorge Community College, Legacy Meridian Park Medical Center, Multnomah County Health Department, Oregon Health Care Association, Portland VA Medical Center, Providence Newberg Medical Center, St. Charles Medical Center, Oregon Health & Science University, University of Portland. Thank you also to Barb Berg and Kelley Ilic for their contributions to this report. Copyright 2010 by The Oregon Center for Nursing

3 CAREER SATISFACTION AMONG OREGON S REGISTERED NURSES: A Report from the Oregon Center for Nursing The Oregon Center for Nursing conducted a survey of Oregon s registered nurses in 2008 to explore career satisfaction among nursing professionals. Following are the reflections of a volunteer who reviewed nearly 1,500 written responses to the survey. Reading these surveys made me proud of nursing, but it also broke my heart. There are so many registered nurses who love their jobs, love their patients, and are doing their level best. These same nurses also relate to laboring under working conditions that are coming close to breaking them. One of the most frequent words I read was Exhausted (and it was definitely with a capital E). Over and over again, these nurses spoke of being short-staffed and overburdened by patient load, to the point of rarely getting lunch or breaks, of being so tired out by 12-hour shifts that they fear making mistakes that might cost them their license. They spoke of inflexibility of working hours/days/shifts/weekends/ holidays that make family life difficult. They feel that while being asked to do more and more with less and less, they continue to be paid at a level not commensurate with the sacrifices they are making. These same nurses expressed their love of nursing, but maybe just not the way nursing is being practiced now. Their concern and care for their patients is evident. They noted it is really the patients who suffer from the working conditions they endure. Many love their job, even if it isn t perfect, and plan to soldier on, because they can t imagine anything else as satisfying. These nurses had much to say about the current state of nursing. It makes me wonder if anyone is listening to them. They really are the subject matter experts! Volunteer survey reviewer, registered nurse with more than 30 years experience Employers need to be creative and flexible with scheduling, using full-time, part-time, 12-hour, 10-hour, and 8-hour shifts. RN with years experience [ 1 ]

4 Issue at a Glance Nurses are at the forefront of patient care. The greatest impact of the nurse shortage is the harmful effect on quality patient care. 1 Recent projections indicate the supply of registered nurses in Oregon will fail to meet anticipated demand by The ability to attract individuals to nursing careers, as well as retain those currently participating in the workforce, is crucial to ensuring an adequate supply of RNs. Career satisfaction among registered nurses impacts the supply of RNs in the short term by influencing currently licensed nurses decisions to participate in the workforce and their choices concerning the number of hours they work. Career satisfaction impacts supply in the long term by influencing non-nurses to pursue careers in nursing. 1 Career satisfaction data can be useful for understanding nurse workforce trends, advising nursing students about career options, providing feedback to employers regarding best workplace practices, and informing decisions surrounding workforce policy. I graduated in May My friends and I all tell the same story: long nights with no breaks, heavy patient loads that risk safety, inadequate staffing, and an average of 13.5 hour days. It will be hard to have a long 10-year career in this field if things don t change. I don t see myself being able to do it until I retire. RN with less than 2 years experience [ 2 ]

5 CAREER SATISFACTION AMONG OREGON S REGISTERED NURSES: A Report from the Oregon Center for Nursing Recommended Actions Needed to Address this Issue Continue to invest in practices that promote healthy workplaces. Continue to invest in leadership development programs for nurses at all levels of practice and in all sectors of care. Conduct nursing research to evaluate outcomes of policies and programs aimed at enhancing career satisfaction among nurses. Conduct additional research with practicing nurses to learn more about recent improvements in career satisfaction and what else should to be done to support the nurse workforce. Encourage new nursing school graduates to consider positions in all care settings. The reasons I am satisfied with my current unit and work are: a good staffing level, good pay, including clinical ladder differentials, and autonomy. RN with 5-10 years experience [ 3 ]

6 Quick Facts about Registered Nurses in Oregon 44,480 Number of licensed RNs in Oregon 48.2 Average age (in years) of an RN licensed to practice in Oregon 27 Percentage under the age of Percentage under the age of 40 working as a nurse full-time 52 Percentage 50 years old and older 83 Percentage 50 years old and older working full-time 54 Percentage working in a hospital setting 7.1 Mean overall career satisfaction score among Oregon RNs in 2002 (best score = 10) 8.0 Mean overall career satisfaction score among Oregon RNs in 2008 (best scrore = 10) Oregon s RNs are most satisfied with... Relationships with patients Relationships with coworkers/colleagues Oregon s RNs are least satisfied with... Benefits Relationships with management [ 4 ]

7 CAREER SATISFACTION AMONG OREGON S REGISTERED NURSES: A Report from the Oregon Center for Nursing Career Satisfaction within Oregon s Registered Nurse Workforce Nurses make up the largest profession within the largest industry in the United States. 3 Among practicing health professionals in Oregon, registered nurses outnumber physicians 4 to 1, pharmacists 9 to 1, and dentists 23 to 1. 4 In June 2009, there were 44,480 actively licensed registered nurses (RNs) in Oregon. 5 The number of licensed RNs has grown steadily over the past 15 years (Figure 1). On average, the number of active licensees increases by 2.3 percent annually. According to a report by Peter Buerhaus that appeared in the Journal of the American Medical Association, avoiding the negative consequences of an entrenched nursing shortage will require actions in three areas: using the current workforce more efficiently; retaining older RNs; and expanding the size of the future RN workforce. 6 Ensuring a highly satisfied nurse workforce will simultaneously influence and be influenced by such measures. Figure 1. Registered Nurses Actively Licensed in Oregon, % 3.7% 3.0% 3.0% 2.8% 3.0% 2.6% 2.3% 2.1% 2.2% 1.7% 1.1% 1.0% 0.5% 0.7% 32,469 33,012 33,695 34,570 34,954 35,144 35,403 36,928 38,042 38,425 39,276 40,456 41,972 43,167 44, % 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Number of Licensees Percentage Change from Previous Year Source: Oregon State Board of Nursing Despite continued growth among their ranks, recent projections indicate the supply of RNs in Oregon will fail to meet anticipated demand by An aging RN workforce has long been understood to be a major driver of the nurse shortage. In Oregon, the average age of RNs is 48.2 years. 5 The number of licensed nurses 50 years of age or older has increased dramatically over the past decade, from 39 percent in 2000 to 52 percent in 2009 (Figure 2). The flood of RNs nearing retirement will continue well into the next decade. Further complicating the situation is the fact that older nurses are less likely than their younger colleagues to work in nursing full-time. Among RNs 50 years and over, 83 percent work as a nurse full-time compared with 92 percent of those under the age of Age Cohort Figure 2. Oregon s Licensed Registered Nurses by Age Cohort, 2000 & years years years years years 70+ years 50% 40% 30% 20% 10% 0% 10% 20% 30% 40% 50% Source: Oregon State Board of Nursing [ 5 ]

8 A national survey of registered nurses in the U.S. found that about 78 percent are satisfied with their principal nursing position. 7 Eleven percent report moderate dissatisfaction and 3 percent report extreme dissatisfaction. To explore career satisfaction among nursing professionals in Oregon, the Oregon Center for Nursing conducted a survey of registered nurses in Respondents are representative of the overall population of Oregon RNs with regard to age. The proportion of respondents working in hospital/acute care settings (60%) is higher than that seen in the general RN population (54%). 5 Fifty-six percent report having worked in nursing for more than 20 years. Using a 10-point satisfaction scale (1 being very dissatisfied and 10 being very satisfied ), respondents rated their career satisfaction in nine specific areas as well as overall. Results indicate that Oregon s registered nurses enjoy a high degree of career satisfaction. 8 The mean overall satisfaction score is 8.0. Survey results suggest that age may play a role in overall career satisfaction. RNs between the ages of 35 and 49 years express less satisfaction than those ages 50 years and over (mean scores 7.7 and 8.2, respectively). Compared with responses to a 2002 survey conducted by the Oregon Area Health Education Centers Program, 9 respondents to the 2008 OCN Registered Nurse Survey report a significantly higher level of overall career satisfaction (Figure 3). Figure 3. Career Satisfaction Among Oregon s Registered Nurses, 2002 & 2008 Average Satisfaction Rating Overall Satisfaction** Relationships with Patients Relationships with Co-workers/Colleagues* Quality of Care I am Able to Provide [2002 Oregon AHEC data not available] Safety of My Work Environment [2002 Oregon AHEC data not available] Level of Professional Autonomy** Number of Hours Worked* Income** Relationships with Management Benefits [2002 Oregon AHEC data not available] Significant difference: *p<.05, **p<.001 [ 6 ] Sources: Oregon Area Health Education Centers, 2002; Oregon Center for Nursing, 2008

9 CAREER SATISFACTION AMONG OREGON S REGISTERED NURSES: A Report from the Oregon Center for Nursing A comparison of the 2002 and 2008 RN surveys also shows increases in mean satisfaction scores in the areas of relationships with coworkers/ colleagues, level of professional autonomy, number of hours worked, and income (Figure 3). The significant increase in satisfaction with income is not surprising. Actual wages for registered nurses increased by 33 percent between 2003 and Real (or inflation-adjusted) wages increased by 28 percent (Figure 4). 10 When employers encounter difficulty in hiring workers, they often respond by offering higher wages in order to boost the appeal of available jobs. Historically, this approach has been used by employers of nurses. Studies have shown that increased wages have positively influenced RN supply in the past. 11, 12, 13, 14 This has been the case for both short-term supply (nurses reentering the workforce or increasing the number of hours worked) and long-term supply (new nurses entering the workforce because nursing is perceived as an attractive career). While higher wages will encourage some nurses to re-enter the workforce or increase the number of hours worked, others will respond by reducing hours because they can make an acceptable wage while working fewer hours. 15 In addition, the effectiveness of wages as a tool to retain nurses is limited. Evidence indicates that working conditions are much more important to nurses than higher wages. 16 Figure 4. Inflation-Adjusted Average Annual Wages for Oregon RNs, $51,783 $52,639 $54,605 $63,864 $66,439 $59, Source: Oregon Employment Department; Bureau of Labor Statistics I do appreciate the flexibility of the nursing field as I can pick and choose my shifts as a relief nurse. 32-year-old BSN hospital nurse with years experience [ 7 ]

10 Figure 5. Career Satisfaction Among Oregon s Registered Nurses by Work Setting, 2008 Average Satisfaction Rating Overall Satisfaction Safety of My Work Environment** Quality of Care I am Able to Provide** Level of Professional Autonomy* Relationships with Management** Relationships with Co-Workers/Colleagues Relationships with Patients** Number of Hours Worked Benefits Income** Hospital Non-Hospital Significant difference: *p<.01, **p<.001 Source: Oregon Center for Nursing, 2008 More than one-half of Oregon s registered nurses (54 percent) work in hospital settings. 5 The remaining 46 percent work in a diverse array of settings including ambulatory care, home health, long term care, and public health. A comparison of RNs by work setting shows some disparities in career satisfaction scores between hospital and non-hospital RNs. Those working in hospital settings are more satisfied with their relationships with management and income. Those working in non-hospital settings are more satisfied with their safety at work, the quality of care they are able to provide, their level of professional autonomy, and their relationships with patients (Figure 5). Organizational characteristics of nurses work environments in acute care settings have been 17, 18 shown to influence patient outcomes. Signalling problems of patient safety, the Institute of Medicine (IOM) has called for the creation of more favorable professional work environments for nurses. 19 The IOM s recommendations target management practices, workforce capability, work design, and creating a culture of safety what will lead to improved satisfaction among nursing personnel and better patient outcomes. Integrating such efforts throughout the health care delivery system will encourage nurses to seek positions across all work settings. [ 8 ]

11 CAREER SATISFACTION AMONG OREGON S REGISTERED NURSES: A Report from the Oregon Center for Nursing Figure 6. Career Satisfaction Among Oregon s Registered Nurses and Nurse Faculty, 2008 Percent Satisfied or Very Satisfied Overall Satisfaction Relationships with Co-Workers/Colleagues Level of Professional Autonomy* Income* 37% Number of Hours Worked* Relationships with Management Benefits 53% 66% 65% 63% 63% 79% 84% 79% 77% 77% 86% 89% 88% Faculty Registered Nurses Significant difference: *p<.001 Source: Oregon Center for Nursing, 2008 A comparison of career satisfaction among Oregon s general RN population (across all work settings and positions) and nurses employed as nurse faculty (previously reported by OCN) reveals several differences. Nurse faculty express a greater degree of satisfaction with their level of professional autonomy than RNs overall, but a markedly lower level of satisfaction with income and the number of hours they work (Figure 6). These results are largely attributable to a stark increase in the student-to-faculty ratio in recent years and considerably lower wages earned by nurses working in academic settings. 20 When asked what policy makers can do to encourage them to remain in teaching beyond their projected retirement date, more than 50 percent of those who responded to OCN s nurse faculty survey said increased compensation would entice them to stay in education longer. 20 This option is preferable to strategies currently used to compensate for unfilled budgeted faculty positions, including hiring more part-time faculty, increasing teaching loads, and limiting admissions/enrollments. 21 These approaches are counterproductive and ultimately perpetuate the problem. I left nursing education, my favorite position of my career, because I can no longer manage a second job in nursing. The second job was a necessity throughout my 10+ year full-time faculty career just to make ends meet. My graduating ADN students made more than I did after 8 to 10 years in teaching with advanced degrees. Given our faculty shortage, this seems a travesty. RN with years experience [ 9 ]

12 Summary The evidence base for the critical role of nursing professionals in ensuring quality care and improving patient outcomes continues to grow, leading to local and national initiatives that have helped nurses gain a stronger voice in system change. A fundamental aspect of such efforts is the improvement of work environments that result in improved satisfaction among workers. A highly satisfied nurse workforce is essential to ensuring an adequate supply of registered nurses. Registered nurses (RNs) in Oregon report a high degree of career satisfaction. In recent years, satisfaction ratings have improved overall as well as in the areas of relationships with coworkers/ colleagues, level of professional autonomy, number of hours worked, and income. There are differences in satisfaction based on work setting, with hospital RNs being more satisfied than non-hospital RNs with some career aspects (relationships with management and income) and less satisfied with others (safety at work, the quality of care they are able to provide, their level of professional autonomy, and relationships with patients). Nurse faculty express a lower level of satisfaction with income and the number of hours they work than the general RN population. Career satisfaction among registered nurses has both short-term and long-term impacts on workforce supply. Efforts on the part of employers, professional associations, and workforce organizations to improve career satisfaction among nurses should aim to create healthier work environments, allow for flexible work schedules that support work/life balance, increase nurses compensation especially in non-hospital settings, and support nurses to practice autonomously and to deliver the full scope of nursing care for which they are licensed. [ 10 ]

15 CAREER SATISFACTION AMONG OREGON S REGISTERED NURSES: A Report from the Oregon Center for Nursing Data Sources The Oregon Center for Nursing (OCN) reviewed existing data sources to explore issues concerning career satisfaction among Oregon s registered nurses. OCN also carried out original research which is described in detail below. Survey of Registered Nurses The Oregon Center for Nursing conducted a survey of registered nurses in Oregon between February and April A cover letter and questionnaire was sent by U.S. Postal Service to a random sample of registered nurses licensed by the Oregon State Board of Nursing. The survey contained fifteen items concerning current employment status, future career plans, retirement plans, and career satisfaction. The instrument also included open-ended questions that asked respondents to identify incentives that would encourage them to increase the number of hours they currently work as well as remain in the workforce beyond their projected retirement date. A total of 2,800 Oregon registered nurses were surveyed, and 865 usable surveys were returned (response rate: 31 percent) and included in this analysis. Respondents are representative of the overall population of Oregon RNs with regard to age. The proportion of respondents working in hospital/ acute care settings (60%) is higher than that seen in the general RN population (55%). Survey of Nurse Faculty In 2008, OCN conducted a survey of nurse faculty in Oregon. The instrument contained items concerning current employment status, future career plans, retirement plans, and career satisfaction as well as a series of questions designed to identify incentives that would encourage nurse educators to increase the number of hours they currently work as well as remain in the workforce beyond their projected retirement date. Of 542 ed questionnaires, 282 usable surveys were returned. Sixteen respondents indicated they were not currently working in a nurse faculty position in Oregon and were excluded from the study. Results from the remaining 266 surveys (response rate: 49 percent) were included in the analysis. [ 13 ]

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